Abstract

Objective: In an effort to reduce waiting times and improve the performance of the clinical indicatorwaiting time relative to triage category, a rapid assessment team was implemented.

Methods: The rapid assessment team consists of the rapid assessment team doctor and triagenurse. The rapid assessment team ensured, wherever possible, that patients weremedically assessed prior to expiration of the waiting time appropriate to their NationalTriage Scale. Waiting time performance indicators, median waiting time and length ofstay during the 3 months the rapid assessment team was operative were compared withthe same period 1 year before.

Results: During the 3 month period where the rapid assessment team was operative, 59.0% ofpatients (n = 5877) were seen within accepted time standards and the median waitingtime was 32 min. This compared with 39.1% (n = 3901) and 50 min, respectively, in thesame period 1 year before (P < 0.001). There was no significant difference in median lengthof stay (3.2 h for both, P = 0.18). Improvements in waiting times occurred in all triagecategories except category 1. Due to a lack of resources and funds, the rapid assessmentteam was discontinued on 4 October 1997.

Conclusions: The rapid assessment team reduces doctor waiting times. Departments consideringimplementing a rapid assessment team should ensure it is funded as a separate resource.

Key words: rapid assessment team, waiting times.

Original Research

Rapid assessment team reduces

waiting timeSteven Grant, David Spain and David Green

Department of Emergency Medicine, Gold Coast Hospital, Southport, Queensland,

Australia

Emergency Medicine (1999) 11, 72–77

Correspondence: Dr Steven Grant, Staff Specialist, Emergency Department, Townsville General Hospital, Eyre Street, North Ward,Townsville, Qld 4810, Australia.

Steven Grant, MB, BS, DA, FACEM, Staff Specialist in Emergency Medicine; David Spain, MB, BS, FRACGP, FACEM, Staff Specialist inEmergency Medicine; David Green, MB, BS, FACEM, Director of Emergency Medicine.

Introduction

The rapid assessment team (RAT) was developed toreduce waiting time to assessment by a doctor andimprove compliance with the Australasian College forEmergency Medicine (ACEM) performance indicator ofwaiting time relative to triage category. This clinicalindicator is used by the Australian Council ofHealthcare Standards (ACHS) to assess quality of careand access.1,2 It is based on the National Triage Scale(NTS), which has been well validated to describe theurgency of large patient populations.3–6

The ACEM has set performance indicatorthresholds defining a reasonable standard for waitingtimes ‘... having regard to issues of clinical riskmanagement, pain management, patient expectation aswell as ethical, legal, social, political and economicconsiderations’1 (Table 1).

In our emergency department (ED), these waitingtime thresholds were not being met. In an attempt toimprove performance, a RAT was implemented. Thepurpose of the present study was to examine the rapidassessment team process in a high-volume ED.

Methods

The RAT approach

The term ‘waiting time’, as used in this paper, refers tothe time elapsed between registration at the triage deskand time of assessment by a doctor. ‘Length of stay’refers to the time elapsed between registration at thetriage desk and time of leaving the ED.

The RAT consisted of the RAT doctor and thetriage nurse. The RAT doctor was a staff specialist ortraining registrar. The role of the RAT was to ensure,wherever possible, that patients were medically

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assessed prior to the expiration of the waiting timeappropriate to their NTS.

A computerized database was used to record timesseen by medical, nursing and clerical staff. Wheneverpossible, computer times were logged in at the time thepatient was seen. Computer times were synchronized.

The triage nurse worked closely with the rapidassessment team doctor and communicated thepresence, location and urgency of each new patientpresenting to the ED. Unless already seen by the usualemergency medical staff, the RAT doctor quicklyassessed each new patient with due consideration oftheir NTS. After introducing himself to the patient, theRAT doctor briefly explained his role and thenconducted a focused history and clinical examination.When appropriate, analgesia and intravenous fluidswere charted and forms for radiology and pathologywere completed. Tasks, such as intravenous (i.v.)cannulation and venesection, were usually performedby nursing staff. If there were concerns regarding thepatient’s clinical needs or stability, a suitably skilledand experienced doctor would be delegated by the RATdoctor to continue their care immediately.

At the time of registration, a standardized form wasproduced, eliminating delays involved in waiting for amedical record. Time seen by the RAT doctor, workingdiagnosis or problem, investigations initiated, i.v. fluidscommenced and drugs administered were recorded onthe form and subsequently attached to the patient’schart. The patient was then seen in the usual mannerby regular emergency medical staff.

The RAT operated from 1 July to 4 October 1997. Aformal roster for the RAT doctor was posted and ranfrom 07.30 to 23.00 h weekdays and 07.30 to 18.00 h onweekends. There were three shifts on weekdays andtwo shifts on weekends, with no overlap. The RATdoctor was drawn from existing rostered ED staff andno additional staff, overtime or added resources wereused.

The percentage of patients seen within the waitingtime appropriate to their NTS, median waiting timeand length of stay when the RAT was operative wascompared with the same period 1 year before. Theintervention period was also compared with the 3month periods immediately before and after (excludingOctober). Waiting times during the intervention periodwhen the RAT was not operating (afterhours) wereincluded in the comparative analysis. Staffing levelsduring all four periods were identical, except duringthe post-RAT period, when an extra night resident wasappointed for 6 weeks of this time.

Table 1. Treatment acuity and indicator thresholds according toNational Triage Scale1

NTS Triage Acuity Indicator category threshold (%)

Resuscitation 1 Immediate 98Emergency 2 Within 10 min 95Urgent 3 30 min 90Semi-urgent 4 1 h 90Non-urgent 5 2 h 85

NTS, National Triage Scale.

Statistical significance testing was performed usingtwo-tailed Chi-squared (Mantel–Haenszel) or Fisher’sexact test for differences between numbers of patientsseen within the required threshold. Because data werenot normally distributed and the variance between thegroups differed significantly, non-parametric statisticaltesting was conducted and median waiting times arepresented. The Mann–Whitney U-test was used toanalyse differences between waiting times in twoperiods and the Kruskal–Wallis test was used toanalyse differences between four periods simul-taneously.

Results

The RAT operated from 1 July to 4 October 1997.Because the RAT continued for only 4 days intoOctober, these 4 days (and the whole of October) wereexcluded from analysis.

During the intervention period when the RAT wasoperative (1 July–30 September 1997), there were 10 476presentations compared with 10 691 presentationsduring the same period 1 year before (1 July–30September 1996). In the period immediately before the

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intervention period (1 April–30 June 1997), there were10 217 presentations compared with 11 437 in the3 month period after (1 November 1997–28 February1998). Table 2 shows the number of presentationsduring each period broken down by triage category.There were 2386 patients (5.6%) who did not wait to beseen by a doctor and 43 patients with missing data fordoctor waiting time. These patients were excludedfrom the analysis of doctor waiting times. Similarly, 76patients with missing data for length of stay wereexcluded from analysis of this outcome.

During the period July to September 1996, 39.08% ofpatients (n = 3901) were seen within the required timesand the median waiting time was 50 min. Thiscompared with 59.0% patients (n = 5877) and a medianof 32 min, respectively, for patients who presented inthe same period in 1997 when the RAT was operative(P < 0.001 for both). In the period immediately beforethe intervention period (1 April–30 June 1997), 43.7% ofpatients (n = 4240) were seen on time and the medianwaiting time was 45 min (P < 0.001 for both). In theperiod after (1 November 1997–31 January 1998), 47.9%of patients (n = 5155) were seen on time with a medianof 44 min (P < 0.001 for both). Figure 1 shows thepercentages of patients seen within the correct times,for all triage categories combined, during theintervention period and in the three control periods.Improvements in waiting times and performanceindicators (percentage of patients seen within therequired time) were seen throughout all triagecategories except NTS 1.

The median length of stay was 3.2 h for both theintervention period and the same period 1 year before(P = 0.18). When the intervention period was comparedwith the other three periods simultaneously, there wasno significant difference (P = 0.09).

A summary of results is shown in Table 3.

Table 2. Number of presentations during each 3 month periodbroken down by National Triage Scale category

NTS 1 July – 1 April– 1 July– 1 November 1997–category 30 September 30 June 30 September 31 January

1996 1997 1997* 1998

1 86 82 95 902 671 586 669 5763 5980 5729 5481 61124 3632 3499 3818 42215 322 321 413 438Total 10 691 10 217 10 476 11 437

*Intervention period. NTS, National Triage Scale.

Table 3. Summary of results

Period Total Did not Missing data Median % Seen in Median length presentations wait (n) for WT (n) WT (min) required time of stay (h)

1.7.96–30.9.96 10 691 685 24 50* 39.1* 3.2†

1.4.97–30.6.97 10 217 509 9 45* 43.7* 3.2‡

1.7.97–30.9.97** 10 476 518 1 32 59 3.21.11.97–31.1.98 11 437 674 9 44* 47.9* 3.2§

*P < 0.001; †P = 0.18; ‡P = 0.02; §P = 0.05.** Intervention/rapid assessment team. WT, waiting time.

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Discussion

Waiting times in ED are an important indicator ofpatient access and are increasingly being recognized asmanagement and funding tools. Examples include theEmergency Department Information Scheme (EDIS) inNSW and the Emergency Services EnhancementProgram (ESEP) in Victoria.7 Clinically inappropriatedelays are now easily monitored through informationtechnology and providing optimal waiting times inincreasingly stressed, busy and expanding ED is amajor challenge for senior management.

Innovative solutions to the waiting time problemmust be initiated within the constraints of a finitebudget and existing resources. Literature regardingwaiting times in emergency medicine has mostlyfocused on length of stay, ED overcrowding and delaysto discharge, rather than on delays to be seen by adoctor. Apart from simple quality assurance methods8,9

to identify processing delays at registration and triage,there are few published strategies to reduce doctorwaiting times.

Fast-track systems have become increasinglycommon in the United States.8–10 These aim tostreamline the care of less urgent presentations, whichare dealt with directly by a specifically trained nursepractitioner (or physician assistant) under thesupervision of a medical officer. This system operatesunder strict triage protocols and is organized in such away that it does not compete with a department’s staff,space or time.11 Triage diagnoses suitable for fast trackare simple uncomplicated problems (e.g. minorlacerations, abrasions, upper respiratory tractinfections). This system focuses attention on patients in

lower triage categories and frees medical staff to focuson more urgent presentations.

Denial of access to emergency care is controversialboth in Australia and the US. The largest experiencehas been in the US: Derlet’s 5 year study, in which31 165 patients (18% of all adult presentations) withdesignated ‘non-emergency conditions’ were out-triaged to primary care facilities without apparentadverse outcome, was limited by a telephone follow-uprate of only 34%.12 Triage guidelines used in this studywere not subsequently validated by a small retro-spective study by Lowe et al. and it was concluded thatthey were insufficiently sensitive to identify patients ingenuine need of emergency care.13

Presently, refusal of emergency care is not commonin Australia. However, at least two hospitals areconsidering triage of NTS 4 and 5 patients to aseparate primary care facility in the hope of reducingdemand for ED care, costs and waiting times.14 Givenan average admission rate of 20 and 5–10% and anaverage doctor time of 41 and 23 min for NTS 4 and 5,respectively, this has been strongly criticized as aninappropriate use of the NTS.14,15

The RAT represents a relatively new method ofreducing waiting times. Although the RAT has beentrialled in some Australian centres, such as Flinder’sMedical Centre (Bedford Park, SA, Australia), noexperience of this has been published in the literature.

Results of the present study show that the RATreduces waiting times in a busy ED. Despite this, in ourinstitution it did not manage to reach ACEM/ACHSstandards, except for NTS 1. During this study, theintervention and control periods had a similar numberof patients in each NTS category and staffing levelsdid not change, except for the addition of one extranight resident during the last 6 weeks of the post-RATperiod. This study shows that 59.0% of patients, of alltriage categories combined, were seen within acceptedwaiting times during the RAT period compared with39.1% in the same period 1 year before ( (P < 0.001).Similarly, median waiting times also improved (32 minduring the intervention period compared with 50 minthe year before; P < 0.001). This is unlikely to be due toonly education, awareness and motivation, as the RAT-period also significantly outperformed both the pre-and post-RAT periods (where 43.7 and 47.9% ofpatients were seen within acceptable time limits andthe median times were 45 and 44 min, respectively;P < 0.001). Despite this, there was no significantreduction in median length of stay. This may be partlyexplained by the fact that the RAT doctor was not

Figure 1. Percentage of patients seen within the required time forall triage categories combined for each 3 month period.

supernumerary and the pool of doctors available toprovide a definitive assessment was reduced. Delaysresulting from exit blocks may also have contributed inthis particular hospital. Improvements in waiting timeoccurred in all triage categories except NTS 1. Thiswas anticipated because patients in need of resus-citation were always seen immediately, regardless ofdepartmental activity or workload, and compliancewith ACEM standards in this category was alreadyachieved prior to initiating the RAT.

In addition to reduced waiting times, the RAT hadother observed beneficial and detrimental effects. Thesewere not formally measured and were mostlysubjective. Advantages included early senior staffinvolvement in the management of new presentations.The RAT doctor performed a useful secondary triageand coordination role and could delegate medicalofficers to see patients requiring acute care. In general,the RAT doctor had a high degree of awareness ofdepartmental activity and flow.

Outcomes, such as time to analgesia, time tothrombolysis and time to availability of radiology andpathology results, were not measured but, anecdotally,these appeared to be reduced in line with waiting times.Further study will be required to clarify these issues.

Although patient satisfaction surveys were notundertaken, the RAT doctor appeared well received. Noadverse comments or complaints pertaining to the RATwere received during the study period. The initialcontact with the RAT doctor was an opportunity toreassure and explain to patients what would behappening in their stay and to give an idea as to thenature of investigations to be undertaken and thelikely time that would be spent in the ED.

There were, however, significant problems with theRAT that offset any perceived benefit. These includedproblems resulting from deploying some of the mostsenior staff at the front end of patient care as the RATdoctor. The RAT doctor was not supernumerary and,because senior staff input occurred near the point oftriage, it was found that registrar and consultant staffwere often unavailable for consultation, supervision ofjunior doctors and management of acute care andobservation ward patients. The RAT doctor wasgenerally extremely busy and could not undertake anyother roles apart from that at the front line, increasingthe workload of other medical staff.

Unfortunately, due to staff limitations, a RAT nursewas unavailable during the study. Subjectively, theRAT greatly increased pressure on nursing staff,particularly in the areas of nurse cannulation, vene-

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section and some initial assessments. Similarly, itcreated a large amount of bed pressure and, by tendingto compress workload, had the effect of increasingdepartmental stress. In general, the RAT role wasconsidered by most registrars and consultants to be themost stressful and demanding job yet undertaken in abusy, high-activity ED.

After careful consideration by senior medical andnursing staff, the RAT was abandoned on 4 October1997. Despite statistically improved waiting times andthe subjective unmeasured benefits discussed above,the RAT was unsustainable in its present form. Theunknown but predictably negative impact of reducedsupervision, consultation and teaching on the laterstages of care, including the vulnerable time ofdischarge was, in large part, responsible for thisdecision. Many of these problems could have beenavoided if the RAT doctor position was separatelyresourced, funded and supernumerary.

This study has several flaws. First, it is non-randomized. Second, although computer times weresynchronized and, therefore, accurate if logged in bymedical, nursing and clerical staff at the time thepatient was seen (which was encouraged), in someinstances data were entered retrospectively usingunsynchronized wrist watches and clocks. Third,reduced waiting times and improvement in the clinicalindicator ‘waiting time relative to triage category’ inisolation does not necessarily imply improved qualityof care. To assess the global impact of a RAT onemergency care delivery, measurement of other out-comes is needed. These include time to analgesia, timeto thrombolysis, time to availability of pathology andradiology, patient satisfaction, staff stress and morale,and appropriateness of radiology and pathologyrequests.

Clearly the RAT is not a panacea for the problem ofprolonged waiting times nor is it a substitute for theneed for more medical staff. Despite this, with extrafunding, resources and adequate floor space, a RATmay be a useful asset to departments seeking to reducewaiting times and improve patient care. A future studyusing medical, nursing and phlebotomy staff togetheras a RAT and looking at these additional outcomes willhopefully be undertaken.

Conclusion

The RAT reduces doctor waiting times in a busygeneral ED. From our experience, a RAT must be

6. Dilley SJ, Standen P. Victorian nurses demonstrate concordancein the application of the national triage scale. Emerg. Med. 1998;10: 12–18.

7. Acute Health Services, Health and Community ServicesVictoria. Emergency Services Enhancement Program.Melbourne: Department of Health and Community Services,1995.

8. Fernandes CMB, Christenson JM, Price A. Continuous qualityimprovement reduces length of stay for fast-track patients in anemergency department. Acad. Emerg. Med. 1996; 3: 258–63.

9. Fernandes CMB, Christenson JM. Use of continuous qualityimprovement to facilitate flow through the triage and fast trackareas of an emergency department. J. Emerg. Med. 1995; 13:847–55.

10. Purnell LD. A survey of emergency department triage in 185hospitals: physical facilities, fast-track systems, patientclassification systems, waiting times, and qualification, training,and skills of triage personnel. J. Emerg. Nurs. 1991; 17: 402–7.

11. Salluzzo RF. Emergency Department Management: Principlesand Applications. St Louis: Mosby, 1997.

12. Derlet RW, Kinser D, Ray L, Hamilton B, McKenzie J.Prospective identification and triage of non-emergency patientsout of an emergency department: A 5-year study. Ann. Emerg.Med. 1995; 25: 215–23.

13. Lowe RA, Bindman AB, Ulrich SK et al. Refusing care toemergency department patients: Evaluation of published triageguidelines. Ann. Emerg. Med. 1994; 23: 286–93.

14. Baggoley C. Primary care patients: What’s the problem? Emerg.Med. 1994; 24: 953–7 (Editorial).

15. Erwich-Nijhout MA, Phillips DG, Baggoley C. The identificationof costs associated with emergency department attendances.Emerg. Med. 1997; 9: 181–8.

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funded as a separate resource and should not beinitiated if it decreases the role of senior staff toprovide supervision, consultation and teaching.

Acknowledgement

We thank Mr Russell Stafford (Epidemiologist, PublicHealth Department, South Brisbane, Queensland) forhis assistance with statistics.

Accepted 22 December 1998

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